Washington Global Health Alliance Discovery Series Peter Piot, MD, PhD March 2, 2009 'The Transformational Nature of the AIDS Response: Opportunities for Global Health'

1. The transformational
nature of the aids response
Peter Piot,MD,PhD

2. A global view of HIV infection
33 million people [30–36 million] living with HIV, 2007
2.2

3. Number of people receiving ARV therapy in low- and
middle-income countries, 2002—2007
3.0
North Africa and the Middle East
2.8 Europe and Central Asia
People receiving ARV therapy (in Millions)
East, South and South-East Asia
2.6
Latin America and the Caribbean
2.4
Sub-Saharan Africa
2.2 Global Fund supported programs
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
end 2002 end 2003 end 2004 end 2005 end 2006 end 2007

4. Decline in adult mortality with introduction of ART:
Botswana
6 50
on ARV
5
Deaths aged 25-54
Registered Deaths (Thousands)
40
Persons on ARV (Thousands)
4
30
3
20
2
10
1
0 0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

5. HIV prevalence (%) among pregnant women attending
antenatal clinics in sub-Saharan Africa, 1997–2007
Southern Africa
50
Botswana
Median HIV prevalence (%)
Lesotho
40
Mozambique
30
Namibia
NOTE: Analysis
20 South Africa restricted to
Swaziland consistent
10
surveillance sites for
Zimbabwe
all countries except
0
1997– 1999– 2001 2002 2003 2004 2005 2006 2007 South Africa (by
1998 2000 province) and
Swaziland (by
region)
Eastern Africa West Africa
20 20
Median HIV prevalence (%)
Median HIV prevalence (%)
15 15
Ethiopia
Burkina Faso
10 10
Côte d'Ivoire
Ghana
5 5
Kenya
Senegal
0 0
1997– 1999– 2001 2002 2003 2004 2005 2006 2007 1997– 1999– 2001 2002 2003 2004 2005 2006 2007
1998 2000 1998 2000
Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.
2.9

6. Number and percentage of HIV-positive pregnant women receiving
antiretroviral prophylaxis, 2004–2007
40
600 000
35
500 000
30
Number of HIV-positive 400 000 % of HIV-positive
25
pregnant women pregnant women
receiving anti-retrovirals receiving anti-retrovirals
300 000 20
15
200 000
10
100 000
5
0 0
2004 2005 2006 2007
Year
Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries.
4.13

7. AIDS IS NOT OVER

8. HIV prevalence (%) in adults (15–49) in Africa, 2007
2.8

9. HIV infections among men having sex with men
in Asia

10. The aids response is transformational
»Science and rights driven
»Political approach
»Focus on results for people
»Multi-disciplinary, multi-sectoral
»Community engagement
»Global response

11. 27 years of responding to AIDS
First cases of unusual immune Global Fund to fight AIDS,
50 deficiency identified Tuberculosis and Malaria
US$10 billion for
Millions
AIDS in
45 HIV identified as The UN General Assembly Special
developing
cause of AIDS Session on HIV/AIDS
countries
40
Four Frees and
WHO launches the
One Care
Global Programme Highly Active
35
on AIDS Antiretroviral
Treatment
30
First HIV First regimen to
3 million
antibody test
25 reduce mother-to-child
on ART in
becomes transmission of HIV President Bush
developing
available
20 announces PEPFAR
world
15 UNAIDS
created
10
5
0
1980 ‘81 ‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 2000 ‘01 ‘02 ‘03 ‘04 ‘05 ’06 2007
People living with HIV

12. Good politics, bad politics: the
experience of Aids
PPiot, HLarson,SRussell. Am J Publ
Health, 2007;97:1934

13. Recorded female deaths in South Africa and Brazil
for ages 15-64 years
Brazil, 2004. South Africa, 1997. South Africa, 2004
Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica.

14. Median percentage of population reached with HIV prevention services
within the specified legal environment
100
Countries
reporting having
80
non-
discrimination
laws/regulations
Median percentage with protection
60
of population for this
reached with population
HIV prevention
services Countries
40
(UNGASS indicator 9) reporting NOT
having non-
discrimination
laws/regulations
20
with protection
for this
population
0
Sex workers Injecting drug Men having
(N=42) users (N=17) sex with men
(N=28)
Source: UNGASS Country Progress Reports 2008.
3.7

15. Treatment Action Campaign (TAC), South Africa

16. UN security Council Resolution 1308 (2000)
on AIDS

17. Total annual resources available for AIDS
1986‒2007
US$ million
10 billion
10 000
8.9 billion
9000
Signing of Declaration of
8000
Commitment on HIV/AIDS, UNGASS 8.3 billion
7000
6000
World Bank
5000 MAP launch
4000
Gates
PEPFAR
3000
UNAIDS Foundation
Less than
2000
US$ 1 million
1623
1000 Global Fund
292
257
212
59
0
‘06 2007
1986 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05
Notes: [1] 1986-2000 figures are for international funds only
[2] Domestic funds are included from 2001 onwards
[i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006)
[ii] 1986-1993 data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996)

18. Resources available to HIV-related programmes
by source and bilateral disbursements, 2006
Total Resource availability for HIV-related Bilateral disbursements to HIV-related
programmes in 2006 (US$ Billions) programmes in 2006
10
(US$ Billions)
9 Other DAC country members 1%
EC (0.5%) Belgium 1%
8
Spain 1%
UN (2%)
7 Norway 2%
6 Australia 2%
GFATM (7%)
Germany 2%
5 Foundations (11%) Canada 2%
4 Sweden 3%
Bilaterals (33%)
Netherlands 3%
3
Domestic Public Ireland 3%
2 and Private (46%) United Kingdom 9%
1 United States 71%
0
Total resources available: US$8.9 Billion Percentage out of the total bilateral disbursements
Total Bilateral disbursements 2006: US$ 2.9 Billion
The organizational disbursements are different than commitments or obligations, as well as different from in-country expenditures
Sources: UNAIDS analysis based on OECD/DAC online database (last visited on May 6, 2008), Resource availability UNAIDS 2005, Funders Concerned About
G AIDS (FCAA), European HIV/AIDS Funders Group (EFG) for Philanthropic sector

19. Disbursements for HIV per US$ 1 Million GDP, 2006
Netherlands 521
Sweden 462
Ireland 408
United Kingdom 328
United States 120
France 93
Germany 60
Canada 50
Japan 24
Italy 4
0 100 200 300 400 500 600
US$
Sources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007;
H International Monetary Fund, World Economic Outlook Database, April 2007.

20. Prices (US$/year) of first-line antiretroviral regimen in
Uganda: 1998-2003

21. Focus on results for people
Targets
Know your epidemic and the
society
Monitor and evaluate
Invest in information systems

22. Know your epidemic

23. Number of HIV infections each year by route of
transmission in Cambodia, 1988-2004
Number of new HIV infections each year by route of transmission in Cambodia, 1988-2004
(Source: Peerapatanapokin and Brown, using Asian Epidemic Model)
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Male clients Sex workers Wife from husband Husband from wife Mother to child
Source: Peerapatanapokin and Brown, using Asia Epidemic Model

24. Impotence fears hit polio drive
By Ashfaq Yusufzai
BBC News, Peshawar
Health officials in Pakistan say they have failed to immunise over 160,000 children against polio
due to rumours the vaccine causes sexual impotence.
Parents in parts of northern Pakistan told the BBC news website they feared an quot;American
conspiracyquot; to cut the fertility of the next generation.
At least 39 cases of polio were reported in 2006, 15 of them in the North West Frontier Province
(NWFP) and the tribal areas in which only 20% of people are immunised. Worldwide 1,902
cases of polio were reported during the year, a recent WHO report said.
A WHO meeting in Geneva last October heard that children paralysed by polio around the world
were infected by viruses originating from Pakistan, Afghanistan, India and Nigeria.
Radio rumours
The main opposition to the drive in Pakistan came from local clerics who run illegal FM radio
channels in many NWFP districts and the tribal areas, say officials.
Amirullah Khan, a resident of NWFP's Swat district, quoted Maulana Fazlullah of a local FM
channel as telling his listeners the vaccination drive was quot;a conspiracy of the Jews and
Christians to stunt the population growth of Muslimsquot;.

25. The PREVENTION GAP
Persons at risk with access to selected prevention interventions, 2006
Source: Global HIV Prevention: the access and funding gap. June 2007

26. Cost Effectiveness

27. A multi-disciplinary, multi-sectoral
response
• Health outcomes determined by multiple
factors and interventions
• Particularly key besides health:
law, education, work place, trade, armed
forces
• Need to expand resource base
• First genuine business engagement in health

28. Percentage of countries with sectors included
in the national AIDS strategy and earmarked budgets
Military/police
Sector
Labour included
Health
Earmarked
Transportation budget
present
Agriculture
Minerals and energy
Trade and industry
Tourism
Public works
0 20 40 60 80 100
Percentage of countries (%), N=126
Source: UNGASS Country Progress Reports 2008.
6.5

29. Community engagement
• From planning to implementation
• Makes or breaks programmes
• “Aids literacy”
• National Aids Councils and Global Fund
Country Coordination Mechanisms
• Societal sustainability and resilience

30. TASO, Uganda

31. A global response
• Global public good and strategic issue
• Role of United Nations
• Global civil society and activism
• International financing
• Generation WE

32. UNITE D N ATION S GENERA L ASSEMB LY
/AIDS
SPECIA L SESSIO N O N HIV
25 - 27 JUNE 2001
United Nations

33. New instruments for AIDS financing
• World Bank Multi-country AIDS Program (2000)
• Global Fund to Fight AIDS, TB and Malaria (2002)
• PEPFAR, (2003)
• Unitaid (2005)
• (PRODUCT) Red (2005)
• Debt2Health (2007)

34. Opportunities for global health
 Increased funding (ODA and research)
 Collateral benefits (TB,malaria, health
systems)
 Culture of accountability
 Tiered pricing
 Engagement of non-medical sectors
 Boost to research
 Major interest by young people
But: how long will the momentum
last?

35. Total health ODA commitments, 2001-2006
$20.1
US$ Billions
$16.5
$13.3
$11.2
$7.6
$7.2
2001 2002 2003 2004 2005 2006

36. Increase in TB financing and new sputum positive cases detected
and treated
Amount disbursed (US$) New SS+ cases treated under DOTS
1.9M
300,000,000 2,000,000
New SS+ cases treated under
Annual amount disbursed
276M
250,000,000
1,500,000
1.4M
DOTS (annual)
200,000,000
196M
(in US$)
150,000,000 1,000,000
127M
107M
100,000,000
0.38M 0.6M 500,000
41M
50,000,000
0.5M
- -
2002 2003 2004 2005 2006 2007

37. Direct Funding of Health Systems through GF
Grants (2007)
Direct funding of health systems through Global Fund grants
Administration
10%
Other
Monitoring and
10%
Evaluation 3%
Infrastructure
and Equipment
Health
9%
Systems
35% Human
Resources
23%
Commodities,
Products, Drugs
45%
Amount (approximately)
• Estimates from Global Fund Rounds 2-•Commodities, Products, Drugs - $6.3-billion
7 proposals •Health Systems - $4.9-billion
•Administration - $1.4-billion
• 100% = $5.2 billion USD •Other - $1.4-billion

38. Increasing Coverage of Health Care in Rwanda
Scaling up Health Insurance Improving Access to Health Care
80%
7,000,000 72%
6,000,000 Global Fund
2005 2006
subsidy 60%
2 m illion
Number of beneficiaries
5,000,000
Global Fund co- 49%
finance subsidy 44% 43%
4,000,000 40%
Out-of-pocket and/or 1,3 m illion 40% 35%
Government subsidy
3,000,000
2,000,000
20%
3 million
1,000,000
900,000
300,000
0 7,800 0%
P rivate health Civil Geno cide Co mmunity
P o pulatio n co verage P o pulatio n with at Utilizatio n rate o f
insurance servants/M ilitary survivo rs, health insurance
with health insurance least o ne district ho spitals
priso ners (398 mutuelles)
co nsultatio n in health
center

39. Basics
• Science AND justice as basis for policy
• Nothing for the people without the people
• Genuine multi-disciplinarity
• Information for accountability and
programming
• Think long term